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The First Case of Psoas Muscle Abscess and Sepsis Caused By 1) DOI : 10.3947/ic.2009.41.2.95 CASE REPORT The First Case of Psoas Muscle Abscess and Sepsis Caused by Actinobacillus ureae in a Chronic Hepatitis B Patient in Korea Woong Chul Lee, M.D., Hee Jung Yoon, M.D., Ph.D. Department of Internal Medicine, Eulji University School of Medicine, Daejeon, Korea Actinobacillus ureae,formerlyknownasPasteurella ureae, is a rare human pathogen. Twenty-eight cases of A. ureae infections in humans have been reported since its first description in 1960. Various predisposing conditions such as skull fracture, alcohol abuse, neurosurgery, schizophrenia, odontal infection, diabetes, HIV infection/AIDS, Waldenström macroglobulinemia, COPD, malnu- trition, rheumatoid arthritis, HCV hepatitis, etanercept, or methotrexate have been associated with infections caused by A. ureae. We report the first case, in the medline-based literature, of A. ureae psoas muscle abscess and sepsis in a HBV carrier patient. Key Words : Psoas abscess, Chronic hepatitis B, Sepsis weakness after suffering from a slip-down injury 25 days before admission while working at his farm. His past me- INTRODUCTION dical history was positive for chronic hepatitis B infection, stroke, and hypertension. He had undergone appendec- Actinobacillus (Pasteurella) ureae is a commensal of tomy and hydrocelectomy. However, he was not a smoker the human respiratory tract and various mammals. It is an nor drank alcohol. organism of low pathogenicity and is a rare human patho- On initial physical examination, he was acutely ill gen (1). Only 28 cases of A. ureae infections in humans looking and showed confused mentality. His body tem- have been reported since its first description in 1960, perature was 38.1℃, blood pressure was 140/80 mmHg, including meningitis (2), pneumonia (3-6), hepatitis (7), pulseratewas96beats/min,andrespirationratewas20 sepsis (7, 8), conjunctivitis (9), otitis media (10), peritonitis breaths/min. Positive clinical findings included tenderness (11), endocarditis (12), chronic bronchitis (13), bone mar- and swelling on the lower back. The chest X-ray was un- row infection (14) and septic arthritis (15). Here, we report remarkable. The abdominal CT showed L4 vertebral body the first case, in the medline-based literature, of A. ureae compression fracture with both psoas muscle abscess psoas muscle abscess and sepsis in a HBV carrier patient. (right: 2.7×1.7×1.3 cm, left: 4.3×2.1×2.3 cm) (Fig. 1). Labo- ratory results were as follows: normochromic normocytic CASE REPORT anemia (Hb = 10.2 g/dL, Hct = 30.0%); white blood cell 9 A 76-year-old male was admitted to the department of count (WBC), 14.21×10 /L (polymorphs, 76.9%; lympho- internal medicine with fever, lower back pain, and general cytes, 9.6%; monocytes, 11.2%; eosinophils; 0.8%); platelet, 427×109/L; erythrocyte sedimentation rate (ESR), 85 mm/ Submitted : 9 October, 2008, Accepted : 16 March, 2009 h; C-reactive protein (CRP), 12.65 g/L; AST, 279 IU/L; Correspondence : Hee Jung Yoon, M.D., Ph.D. ALT, 142 IU/L; ALP, 198 IU/L; total bilirubin, 0.8 mg/dL; Division of Infectious Diseases, Department of Internal Medicine, Eulji University School of Medicine, Daejeon, Korea prothrombin time, 20.6 sec (INR=1.88). Other blood bioche- 1306 Dunsandong, Seogu, Daejeon, 302-799, Korea Tel : +82-42-611-3096, Fax : +82-42-611-3853 mistry tests were normal (Table 1). His HBsAg was posi- E-mail : [email protected] Actinobacillus ureae Infection in a Chronic Hepatitis B Patient Vol.41, No.2, 2009 95 tive and HBV-DNA was 393,900 copies/mL. The patient turned to normal values. Follow up abdominal CT scan was initially treated with intravenous ceftazidime and after 25 days of treatment showed reduced size of right metronidazole. On the 7th hospital day, the fusion opera- psoas abscess to 1.0×2.3×1.5 cm and disappeared left psoas tion of L4-5 vertebral body and incision and drainage was abscess. A repeated blood culture performed on 14 days performed. The blood culture was positive for A. urea, and 30 days after admission revealed no growth. After 30 which was susceptible to penicillin, amikacin, ampicillin, days of intravenous antibiotic therapy, he was discharged aztreonam, cefazolin, cefotaxime, ciprofloxacin, gentamicin, with oral cefixime for 2 weeks. He was afebrile on control and cotrimoxazole. Antibiotics were changed to ceftazidi- visit in outpatient clinic after 2 weeks. me.Echocardiographyshowednovegetationoncardiac valves. A few days after treatment, fever subsided and in- flammatory indices such as ESR, CRP, and platelets re- Figure 1. L4 vertebral body compression fracture and osteolytic lesions were seen. In both psoas muscles, the elongated hypodense lesions with peripheral enhancement were seen. (right: 2.7×1.7×1.3 cm, left: 4.3×2.1×2.3 cm) Table 1. The Laboratory findings of the Patient Laboratory findings Hospital day 1 Hospital day 54 White blood cell (x109/L) 14.21 7.09 polymorphs (%) 76.9 71.2 lymphocytes (%) 9.6 13.8 monocytes (%) 11.2 8.5 eosinophils (%) 0.8 0.7 Platelet (x109/L) 427 334 Erythrocyte sedimentation rate (mm/hr) 85 10 C-reactive protein (g/L) 12.65 0.5 AST/ALT (IU/L) 279/142 56/25 ALP (IU/L) 198 95 Total bilirubin (mg/dL) 0.8 0.9 Prothrombin time (sec) 20.6 (INR=1.88) 12.9 (INR=1.04) 96 Infection and Chemotherapy : Vol.41, No.2, 2009 Figure 2. Post-operation state. Bilateral psoas abscesses were more reduced to 1.0×2.3×1.5 cm (rt.) and 3.5×1.4×1.5 cm (lt.) on follow-up CT. environmental localized mammalian flora. DISCUSSION Since its first description by Minter in 1881 (17), a psoas abscess has been a rare, but life threatening disea.se. The Aureaeis a small, non-motile, vacuolated, bipolar- psoasmuscleliesincloseproximitytoorganssuchasthe staining, pleomorphic organism and is gram-negative rod sigmoid colon, appendix, jejunum, ureters, abdominal aorta, that grows well on media containing blood. The organism kidneys, pancreas, spine, and iliac lymph nodes. Hence in- is most often a harmless commensal. However, under con- fection in these organs can spread to the iliopsoas muscle. ditions of immune compromise or disruption of normal The abundant blood supply of psoas muscle is believed to physical barriers to infection, it can lead to serious illness. be a predisposing factor for hematogenous spread from Various predisposing condition such as postsurgical infec- occult sites of infection (18) and this is called primary psoas tion, periodontal disease, emphysema, alcohol related cir- abscess. About 18-20% of primary psoas abscess is rhosis, skull fracture, alcohol abuse, neurosurgery, schi- associated with history of trauma (19). Thus this case could zophrenia, odontal infection, diabetes, HIV infection/AIDS, also be classified as primary psoas abscess. Staphylococcus Waldenström macroglobulinemia, COPD, malnutrition, aureus is the most common causative organism of primary rheumatoid arthritis, HCV hepatitis, etanercept, or metho- psoas abscess and Streptococcus species and Escherichia trexate have been associated with infections caused by A. coli are common in secondary psoas abscess (19). ureae (1-15). In this case, chronic hepatitis B was an A.ureae strains are susceptible to most antimicrobials underlying immune-compromised condition, which is a including ampicillin, cephalothin, cefoxitin, tetracycline, predisposing factor that is not previously mentioned in aminoglycosides, and trimethoprim-sulfamethoxazole. Pe- literature, and this may impair the defense against the nicillin is favored as the first line antibiotic for invasive organism.AsmostofthegenusActinobacillusspeciesare disease, followed by erythromycin and third-generation commensal or pathogens of animals, especially cattle, cephalosporins (15). In this case, the isolate showed sus- horses, and pigs, history of trauma or recreational acti- ceptibility to all antibiotics and he was successfully treat- vities may provide important clues for establishing early ed with ceftazidime. diagnosis (15, 16). This patient had a history of slip-down Other diagnostic modalities are available. Molecular injury while working at his farm. Therefore, it could be biology-based techniques have proved useful for the postulated that the origin of A.ureae in this case is from detection and identification of organisms that are difficult Actinobacillus ureae Infection in a Chronic Hepatitis B Patient Vol.41, No.2, 2009 97 or impossible to culture in vitro. In addition, analysis of 8) Barardi L, Bourdain J, Chatelain R, Riou J. Diagnostic DNA sequences has been used to name organisms that bacterioligque de Pasteurella ureae: a propos d'un cas de septicemia humaine. Med et Maladies Infect were unidentifiable by phenotypic testing (20). 14:36-40, 1984 Of the documented cases in the literature, this is the 9) Bogaerts J, Lepage P, Kestelyn P, Vandepitte J. Neo- first case, to our knowledge, of a serious A.ureae infection natal conjunctivitis caused by Pasteurella ureae. Eur J associated with psoas muscle abscess that has been Clin Microbiol 4:427-8, 1985 10) Bigel ML, Berardi-Grassias LD, Furioli J. Isolation of documented in HBV carrier without progression to liver Actinobacillus urea (Pasteurella ureae) from a patient cirrhosis. When a patient with psoas muscle abscess is with otitis media. Eur J Clin Microbiol Infect Dis 7: found, the possibility that uncommon organism could be 206-7, 1988 the cause of infection should always be seriously con- 11) Noble RC, Marek BJ, Overman SB. Spontaneous bacterial peritonitis caused by Pasteurella ureae. JClin sidered and effort should be made to identify species and Microbiol 27:375, 1989 obtain antibiotic susceptibility. This will lead to early 12) Yamamoto K, Ikeda U, Ogawa C, Fukazawa H, Eto M, initiation of appropriate antibiotic therapy resulting in Shimada K. Pasteurella ureae endocarditis. Intern Med successful treatment outcome. 32:872-4, 1993 13) Vay C, Rodríguez C, Sadorin R, Vujacich P, Famiglietti A. Actinobacillus ureae isolated from a patient with REREFENCES chronic bronchitis.
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